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Patients with severe aortic stenosis are increasingly treated with transcatheter aortic valve implantation (TAVI) as a safer option to surgical aortic valve replacement (sAVR). Similar to many other heart diseases, after the specific therapeutic intervention patients are eligible for cardiac rehabilitation (CR) for the purpose of functional recovery. Thus far, CR after both sAVR and TAVI has been used to a limited extent, as shown by the availability of only two meta-analyses including 5 studies and 6 studies, respectively. Recent observational studies reported a significant improvement in functional indexes such as the Barthel scale and the 6-minute walk test (6MWT). We evaluated the outcome of CR in patients after TAVI treatment by measuring changes in the commonly used Barthel scale and 6MWT and adding the short physical performance battery (SPPB) scale as an index to assess lower extremity function. All indexes demonstrated a significant improvement, namely p

Cardiac rehabilitation (CR) is the subspecialty of clinical cardiology dedicated to the treatment of cardiac patients, early and in the long term after an acute event. The aim of CR is to improve both quality of life and prognosis through prognostic stratification, clinical stabilization and optimization of therapy (pharmacological and non), management of comorbidities, treatment of disability, as well as through the provision and reinforcement of secondary prevention interventions and maintenaince of adherence to treatment. The mission of CR has changed over time. Once centered on the acute phase, aimed primarily at short-term survival, the healthcare of cardiac patients now increasingly involves the chronic phase where the challenge is to guarantee continuity and quality of care in the medium and long-term. The aim of the present position paper is to provide the state-of-the-art of CR in Italy, discussing its trengths and weaknesses as well as future perspectives.

In the present work, the current activities of Cardiovascular Rehabilitation and Prevention (CRP) in the ambulatory setting of the Lombardy Region (Italy) are described. Based on the 2012 Legislation, ambulatory CRP is delivered by means of three programme categories (MAC 6, 7, and 8) with different degrees of intensity. The patient evaluation of global cardiovascular/clinical risk, comorbidity, and disability is the cornerstone for MAC prescription. Following the organization of MAC activities, a survey on 327 patients was carried out by the regional network of the Italian Society of Cardiovascular Rehabilitation (GICR-IACPR). Globally, acute coronary syndromes (with or without coronary revascularization) constituted the main access group to CRP. More than 60% of patients displayed a condition of high risk, comorbidity, and disability. The outcome of ambulatory CRP by means of MAC 6 and 7 was satisfactory, while in the 'less intensive' MAC 8 patients with complete drug up-titration and achievement of secondary prevention targets were no more than 70%. Riassunto La Cardiologia Riabilitativa e Preventiva (CRP) storicamente riconosce nei percorsi ambulatoriali un importante setting per l’erogazione dell’intervento. In Regione Lombardia negli ultimi anni le attività di CRP sono state oggetto di una profonda riorganizzazione, con il contributo di esperti GICR-IACPR attivi presso lo specifico tavolo tecnico attivato presso la Direzione Generale Sanità. Dal 2012 sono attive le Macroattività Ambulatoriali Complesse e ad alta integrazione di risorse (MAC), che riguardano anche la sfera della CRP. Le MAC si sono poste come integrazione e alternativa al percorso degenziale e sono state classificate in tre livelli a complessità decrescente (MAC 6, MAC 7 e MAC 8 nel nuovo nomenclatore delle attività ambulatoriali). Il network GICR-IACPR ha quindi successivamente condotto una survey su 327 pazienti in tre Centri di CRP, di cui vengono esposti i risultati. Complessivamente, le condizioni di accesso alle MAC più utilizzate sono stati gli esiti di sindrome coronarica (con o senza rivascolarizzazione) e vi è stata una robusta rappresentazione (oltre 60%) di situazioni cliniche a medio/alto rischio clinico, complessità e disabilità. L’outcome dell’intervento in regime di MAC (in termini di recupero funzionale, titolazione della terapia di cardioprotezione e raggiungimento dei target terapeutici) è stato globalmente soddisfacente, seppure minore (non superiore al 70%) nel MAC 8 meno "intensivo".

Background and aims: Poor adherence to clinical prescriptions has been recognized as a major problem in management of chronic diseases. Only few studies tried to identify which factors could be considered predictive of low adherence to pharmacological and non pharmacological prescriptions in Coronary Heart Disease (CHD) patients. The aims of our observational-longitudinal study were to assess in CHD outpatients admitted to a Cardiological Day Hospital (DH): self-reported knowledge and acceptance about illness, perceived self-efficacy in disease management and emotional status, and the possible relationships among these variables. Methods: Patients were assessed at baseline during the first days of DH and few days before discharge (follow-up) by the Adherence Schedule in Ischemic Heart Disease (ASIHD) and by the Anxiety and Depression Scale (AD). The ASIHD is a tool specifically aimed at evaluating the cognitive, relational and behavioural antecedents of adherence to treatment of patients suffering CHD. The rehabilitation programme comprised: individualized physical training, nutrition monitoring, psychological assessment and psychoeducational interventions, when indicated. Baseline and follow- up clinical data, ASHID and AD scores were analysed both considering the whole sample (n=117) and the subgroup which met the clinical criteria for psychological counselling (n=35, psychologically treated group). Intracorrelation and intercorrelation coefficients of the whole sample baseline data were calculated among ASIHD, AD scores and socio-demographic data. Results: Our CHD outpatients (62.6±9.3 years) were mainly male, married and retired. They had 5,2 years of illness on the average, and only 9% of them were still smokers, whereas 62% had smoked in the past. Total and LDL cholesterol levels showed a significant reduction at follow up evaluation. Among ASIHD baseline item scores, many statistically significant intracorrelations emerged, in particular: disease limitations acceptance showed significant positive correlations with disease knowledge (r=.34, p=.0001), family/friend support (r=.27, p=.003), following dietary prescriptions (r=.38, p=.0001), exercise (r=.35, p=.0001), taking medicines punctually (r=.35, p=.0001), identifying physical/ psychological fatigue (r=.45, p=.0001), monitoring clinical parameters (r=.42, p=.0001), management of stressful situations (r=.26, p=.006), and reducing stress sources (r=.34, p=.0001). Concerning the significant intercorrelations between AD and ASIHD scores, disease acceptance showed negative correlations with anxiety and depression (r=-.27, p=.004; r=-.26, p=.004 respectively). Conclusions: The pathway stemmed from our data enlights that in the area of cognitive and relational antecedents of adeherence, accepting the disease limitations can be considered a central issue in CHD patient’s illness adjustment and prescriptions adherence. Moreover, the ASHID resulted a useful synthetic schedule of psychological/behavioural variables regarding perceived self-efficacy in disease management. This may facilitate a synergic team work on common priorities that respect the point of view of the patient and the clinical-rehabilitation purposes.

Despite major improvements in diagnostics and interventional therapies, cardiovascular diseases remain a major health care and socio-economic problem in Italy. Costs and resources required are increasing in close correlation to both the improved quality of care and to the population ageing. There is an overwhelming evidence of the efficacy of cardiac rehabilitation (CR) in terms of reduction in morbidity and mortality after acute cardiac events. CR services are by definition multi-factorial and comprehensive. Furthermore, systematic analysis and monitoring of the process of delivery and outcomes is of paramount importance. The aim of this position paper promoted by the Italian Association for Cardiovascular Prevention and Rehabilitation (GICR-IACPR) is to provide specific recommendations to assist CR staff in the design, evaluation and development of their care delivery organization. The position paper should also assist health care providers, insurers, policy makers and consumers in the recognition of the quality of care requirements, standards and outcome measure, quality and performance indicators, and professional competence involved in such organization and programs. The position paper i) include comprehensive CR definition and indications, ii) describes priority criteria based on the clinical risk for admission to both inpatient or outpatient CR, and iii) defines components and technological, structural and organizing requirements for inpatient or outpatient CR services, with specific indicators and standards, performance measures and required professional skills. A specific chapter is dedicated to the requirements for highly specialized CR services for patients with more advanced cardiovascular diseases.

In Cardiovascular Rehabilitation the increasing inpatients complexity suggests the necessity to develop screening methods which allow to identify those patients that require a psychological intervention. Material and methods: A Psycho-Cardiological Schedule (PCS) was developed with the aim of detecting the critical situation indicators or the presence of psychological, social and cognitive problems. The PCS, compiled by a nurse or cardiologist in collaboration with a psychologist, allows to assess the need for a deeper psychological examination, clinical and/or with tests. Aim of the present study is to identify the convergence levels among the observational and anamnestic data of the PCS collected by a nurse and the clinical and/or test data of the psychological deeper assessment. Results: Among the 87 patients recruited in January- February 2010, 28 (aged 53.5±12.6, M=20, F=8) fulfilled the criteria for a deeper psychological examination: age

Peripheral arterial disease (PAD) is a frequent comorbidity among patients entering cardiac rehabilitation (CR) programmes and an important source of disability and impaired prognosis. The prevalence of PAD across the wide range of conditions for CR is poorly understood, as far as its impact on drug optimization and intervention delivered. The “ATHerosclerosis of the lower extremIties as a liNKed comorbidity in Patients Admitted for carDiac rehabilitation” (THINKPAD) study was carried out by the Italian Association for Cardiovascular Prevention, Rehabilitation and Epidemiology (GICR-IACPR) in order to explore PAD both as a comorbidity and a primary indication at the entry of CR. The study was a retrospective case series. In the study period (from May 1, 2012 to June 30, 2012), data on consecutive patients discharged from 17 CR units in Northern Italy were collected. Web-based electronic case report forms (e-CRF), accessible in a dedicated section of the IACPR website (www.iacpr.it), were used for data entry, and data were transferred via web to a central database. The data collection instrument was designed with a multiple choice format, with jump menus or select boxes and obligatory items. A sample size of 1,300 subjects is expected, with first data available by the end of 2012.

Obstructive sleep apnea (OSA) is a highly prevalent sleep-related breathing disorder, often unrecognized and undiagnosed, in patients with established cardiovascular diseases. Considerable evidence is now available in support of a significant association between OSA and increased risk for cardiovascular disease morbidity. OSA has also been recognised as a potential public health issue associated with societal consequences including accidents and work economics. Treatment of OSA would reduce cardiovascular risk and the overall usage of health care resources. OSA might be a modifiable risk factor and screening for OSA should be implemented in cardiac rehabilitation settings.

Background: The prognosis of chronic heart failure (CHF) remains poor despite advances in medical management. Several different variables determine prognosis. Recently anemia has emerged as an independent prognostic variable in the evaluation of CHF. It is therefore important to analyze the role of anemia in patients with mild to severe CHF already well characterized by hemodynamic, echo- Doppler, and cardiopulmonary exercise testing. Objective: We performed this study to evaluate, in a large general cohort of CHF patients, the frequency of anemia and its correlation with their clinical profile. We assessed the prognostic value of anemia in relation to other known prognostic variables. Methods: Two-dimensional echocardiography, right heart catheterization, cardiopulmonary tests and laboratory examinations were performed in a population of 980 consecutive patients with CHF (53±9.4 years, 85% male, LVEF 25±8%; 45% with NYHA class III-IV). A hemoglobin (Hb) concentration less than 12 g/dl was used to define anemic patients. The primary end point was cardiac death or urgent heart transplantation. Results: Nineteen percent of patients were anemic. These patients had a lower body mass index (24±3 vs. 25±4 Kg/m2 p

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